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• What does it really mean to embrace a continuous improvement culture? - NHS ConfedExpo 2024

Penny Pereira

Hello and welcome to this episode of Leading Improvement in Health and Care, the new podcast from the NHS Confederation, the Q Community and the Health Foundation. 

Matthew Taylor

So we are, as you can no doubt hear, recording this special edition live at NHS Confed Expo 2024. This is the event where every year the NHS Confederation and NHS England bring together leaders and teams from across health and care.

We're sitting here in a huge exhibition hall surrounded by people who've got great ideas around innovation. We've got robots, we've got consultancies, we've got voluntary sector improvement zones. There's a real buzz. Um, I'm Matthew Taylor, CEO of the NHS Confederation. You probably should have said that at the beginning, shouldn't I?

Penny Pereira

Hi, and I'm Penny Pereira, managing director of the Q Community at the Health Foundation. 

Matthew Taylor

Now, if you keep an up to date calendar, you'll know we're recording this podcast before the general election. So we're sitting here not knowing what the outcome of that election will be, and you're sitting there listening to it, knowing what the outcome has been.

But I think that by this podcast reaches your ears. Everything we chat about is going to be more relevant than ever, because there's a lot in this event, a lot of conversation at the moment about implementing major change; any new government, whoever wins- they'll be talking a lot about change.

So how do we make change happen? And how can any government set about meeting its ambitious improvement goals? So whilst we've been here, both Penny and myself have been meeting with colleagues from the NHS and beyond to talk about all things improvement. 

Penny Pereira

So I led a workshop exploring practical strategies to improve health and care across systems.

for joining us. And Matthew, you chaired a big main stage panel discussion about improvement in this episode. We're going to be bringing you highlights from both of those sessions. And it'd be great to start off with you, Matthew. You facilitated with Panache a really interesting panel discussion on what it means to embrace a continuous improvement culture.

And I was sitting very keenly on the front row. I was really struck by just how rich the discussion was. You were joined by leaders from East London NHS Foundation Trust, Northeastern Northumbria ICB, National Voices and NHS England. The whole session is available to watch in full on the NHS Confederation's YouTube channel But can you just give listeners a sense of the big ideas from the discussion?

Matthew Taylor

Yeah, thanks Penny. I'm going to pick out two, I think. The first is something which I know you'll have thought a lot about, which is this relationship between the kind of hard and soft side of improvement. So the hard side is about technique. You know, this is a science, as Amar said in the session. But on the other hand, a lot of focus on culture and mindset, and trust and relationships. So that was the first thing. 

You've got to hold these two things in your mind. If it's all about technique and science. You won't bring people with you, but if it's all about relationships and vision, you won't get anything done. So that I thought was, was kind of interesting to hear that.

And then the second thing was this notion that I used in my speech yesterday, but this kind of notion of split-screen thinking. So one of the things I said, Penny, which may well be a phrase I got from you, I don't know, but I said, you know, when we talk about improvement, it's often about how we do things better, but it also needs to be about how we do better things. Which is, yes, we've got to tackle the challenges ahead of us, but we've also got to have a vision of doing things very differently.

And so the other thing that I think rolled through the conversation, and I think which reflects the frustration of many leaders at the moment is. As well as improving the way things are now, we've got to be opening up the space to do things very differently in the future. So those, those are my two big themes.

Penny Pereira

I think those were really prominent and interesting themes in the session. Actually, the first couple of clips that I've chosen from my selection as an audience member actually explores this ambition for reimagining health and care, recognising that You know, that's what's needed, that side of the split screen, not just kind of incremental improvement of the here and now.

First is Dr Vin Dvorka, interim national director of transformation for NHS England, and the second voice you'll hear will be Sam Allen, chief executive of North East North Cumbria ICB. 

Vin Dvorka

We know that in order to deliver the kind of services and to support our populations, we've got some big shifts we need to do.

Prevention, moving to population health, moving to place-based care, parity of esteem, not just a physical and mental health, but the social determinants of health, life course approaches from pregnancy to palliation, but as well as being a more productive health system and being a personalised health system that really meets the needs of people.

If we are going to be able to create a new system that's like that, that's genuinely integrated and personalised and enabled by digital technologies and delivering the kind of fantastic advances in healthcare at one end of the health spectrum, if you're really unwell, but really fantastic integrated care at the other end of the care, we've got to have that one eye on the future and say, these are the care shifts that we need to be able to shift to.

And so what we've got to do is look at everything that we are supporting staff and patients to improve locally, but have that eye on the future horizon and say, how does that. So I'm not just improving my outpatient processes, 

I'm also saying how am I going to deliver a completely different model of care to support the children I look after with increasing numbers of long-term conditions? Because children that sadly would've died when I was a young junior doctor and now thankfully surviving into adulthood. 

Sam Allen

So, when I sort of think back to when I first became the chief executive, what are the things that were occupying my mind and dominating the majority of discussions? It was things like ambulance handovers, ED performance, but of course, those are all symptoms of what's happening in our wider community. 

So your point Matthew around split-screen thinking, if we just take a sort of a performance management orientated approach to fixing things, are we likely to improve things? Yes, probably. Are they likely to be sustainable in the long term? No, because what we haven't done is we haven't co-produced solutions and also the people who have the ability to make the best changes, are the people doing the work, who are on the receiving end of the work.

So absolutely, from an NHS perspective, we need to support NHS impact, but we need to think beyond that. We have to think about our wider partners. So our approach needs to be inclusive and not exclusive. In a system we can't be top down, so anything that we do has to be co-produced. So how do we do that?

It takes time. So how in a system do we build the space where people working in the system, people receiving services in the system can come together? And our role as a system is to be able to convene people to come together.

Matthew Taylor

So, really interesting hearing Sam there talk about including people in the process.

There was something else Sam said, that actually the kind of hierarchical way of thinking about change just doesn't really work in the way that it did before. What I sense, is we are in the process of reimagining leadership. And at the heart of that is moving from a model where leaders at the top of a hierarchy to a model where leaders are in the middle of a kind of an ecology of learning and development.

So, I think that's really interesting, but as someone who's been a leader myself in lots of different organisations, reimagining yourself from the top of the pyramid to being the centre of the kind of ecosystem. It's a really, really big shift. 

Penny Pereira

Indeed. I really feel that challenge in terms of my own leadership practice, and we support a lot of people in the Q community who are helping to go through that.

I think what I found helpful is to not be too intimidated by the idea of that leadership shift in the abstract to really be thinking about what does that look like in terms of practical habits and behaviours? And I think there were some great examples from the conversation this morning. So Vin was talking about doing huddles where the chief exec is standing in the open foyer of the hospital working and listening from clinical teams and then from patients who are walking by about the improvement work that's going on and the challenges that are there and using that as a starting point for change. 

And then I think we really need to be building the infrastructure around this to be able to move from an aspiration that I think everybody has to be leading in a less hierarchical way to actually, what are the processes and infrastructure that make that possible? So I heard from north east Northumbria, the infrastructure they put around bringing people together, making sure that they actually have some proper time and space to learn from each other. 

Matthew Taylor

For me, I think you have to remember as a leader is organisations are odd, artificial and strange things, you know, and we need them. 

We can't organise life without organisations, but we have to understand, and you know, I'm a sociologist by background, so I think, you know, Weber's analysis of bureaucracy is still really powerful. That bureaucracy is something that you need for systems to work, but it has lots of peculiarities that you've got to continually guard against.

And I think one of the ways in which my leadership practice has evolved is just constantly reminding myself that organisations are odd things. And if you're not subverting the logic of hierarchy and bureaucracy on a pretty regular basis, such as standing in a huddle in front of all your staff, such as being really open yourself, such as really creating egalitarian processes where voices are all given equal kind of status.

If you don't do that, then the kind of brutal logic of organisations takes over and that makes change much more difficult. 

Penny Pereira

I think we need to recognise that as leaders, especially when we've got big change goals, really big transformation, re-imagining health and care, that is partly about the individual leadership practice, the conversations we have, the way in which we interact with people, but we should also be playing the role of architects of the organisations and systems. 

And not only are our organisations false constructs, but because that's the way they're organised, it makes it all the more difficult to do the cross system change. And so actually sometimes we need to create a different kind of structure to get at what one of the panellists this morning talked about, the exciting space in between organisations.

And wouldn't it be nice if as ICSs kind of go about their work, they don't just create an equivalent type of bureaucracy that spans organisations, but actually imagine a different kind of connecting, a different kind of working, a different kind of bureaucracy, perhaps, that is more enabling.  

Matthew Taylor

Let's pick up a couple of perspectives on this question of the evolution of leadership roles. 

Now let's hear from Amar Shah. He's the national clinical director for improvement and a consultant forensic psychiatrist and chief quality officer at East London NHS Foundation Trust. And he's been in the kind of improvement business for a long time in very practical ways. 

And then we're going to hear from Sarah Sweeney, who's director of membership and development at National Voices.

Amar Shah

People need to feel like they can contribute to solving the problem, that their lived and learned experience as clinicians or service users or in the local community is actually valued and that there's a way for them to bring that into the solution. And then they need to feel like they have permission to act. And those are really the core components of culture.

And culture is really how each of us behaves all the time and how we interact with each other. It's a relatively fragile thing. And it's made up continuously of our own behaviours. And to get to that point, really it's about belief, in many ways. Improvement is both a mindset and a method. And the mindset is really about how we act, how we are, what we believe.

And to really build belief in improvement, you have to recognise the value of utilizing people's experience and wisdom in solving problems. I mean, there's a fundamental question here about do we think the problems are best solved at senior levels or at the point of care? What is our current mindset about and mental model about how problems should be solved?

And the only way really for people to believe that there is a different approach to this which involves people and their own lived experience in identifying and solving problems is, is through being really proximal and close to the work. 

So for us to really create this culture, I think we need particularly for, for leaders, the responsibility of seeing their role very differently.

Many leaders have got gone into senior roles through being expert problem solvers, and suddenly they're in a role now where they're not expected to problem solve anymore. They shouldn't be problem solving. Actually, our role now is problem framing and creating the climate in which others can solve problems.

That's very different, and we need to sort of learn our way into that, unlearn some behaviours and learn some new ones. It's really think about what that means for us as leaders to create that climate. 

Sarah Sweeney

I think some of the things I recommend are very practical things like working through trusted intermediaries, for example, volunteer sector organisations who have trust and recognition within communities who haven't been well served by services.

I think recognising that you can't expect people to come to you, that you have to go and meet communities and people where they're at. So it's not just a case of opening the door and putting a sign up. That's not going to attract the types of people who are already not well served by services and things.

Because the last thing you want to do with your free time, if you've just been treated very badly within the service, is to spend some more time in the same service. So it's looking inroads into communities. And I think it is a long term investment. And I think that's some of the issue and challenges we've seen is that sometimes I think people expect to see like immediate results of engagement immediately, meaning that people are like instantly happier.

But often the kind of narrative or the issue that communities have been experiencing over very many years and the amount of time it takes to build trust back with communities is over very many years. So sometimes you see a programme going in for one year and then disappearing. So you know, addressing the trust issues and then just disappear back into the ether again.

So something for you, for individuals as professionals, it might feel like a one-off transaction where you just want to get input into this one decision, but for that person, that's their whole life story. be a really traumatising event for them. It's trying to think about what is it that the individual wants to get from this and trying to look at, I guess, relational approaches as well.

But I think that argument is underpinned by investment in the infrastructure and in communities. And I guess that's a reflection of the dignity that you give to people, the respect and the enthusiasm as well that you really want to hear from them. 

Penny Pereira

So it was really fascinating conversation. I'm reflecting on this question of the time that it takes to achieve improvement and change of the scale that we're talking about. 

And the fact that I think improvement done well can help us move from this big future vision that we need to reimagine into actually the practical steps that will be the bridge to get there. The way that we pace that work needs to make sure we invest in properly up front, actually doing the co production, creating the right relationships and connection for change. But then create a space where you can actually have a good pace of change work, where people feel like they're able to actually get on and practically problem solve.

Matthew Taylor

Yeah, so I, I agree with that Penny. I think it is important and I want to respond to that, but just to acknowledge The point that Sarah is emphasising that, you know, patients, patient representatives have got to be at the centre of this. And where I look at fantastic improvement practice, one of the things that is recurrent in that is an unerring focus on improving patient experience.

And you can't improve patient experience unless you're asking patients themselves what matters to them. Because actually what matters to patients isn't always what the data we collect suggests matters to us. 

But as to your point about time - the NHS does suffer, and we've just come out of an election campaign, people listening to this, we've just come out of an election campaign - we do suffer from short termism. 

But tell me more, Penny, about this question of pace. Because on the one hand change takes time and leaders say to me over and again, I was at an NHSE gathering of leaders a few weeks ago and one of the leaders got up and said, look, I really want to improve productivity, but I can't do it in six months.

On the other hand, a certain amount of pace is important, isn't it? You know, because if people don't see improvement, they just get bored. There's other things that they can do. So what's your advice to people doing improvement work about how to articulate this pace challenge? 

Penny Pereira

I think improvement at its best does have a really healthy pace where people feel like they have the opportunity to input, but they're also seeing progress as they go.

I think that Sam elsewhere in the session talks about how there was really big transformation goals that we got, but actually we, we need to avoid being paralyzed by the size of that transformation goal, but actually the big transformations are made up of many, many incremental steps. And I think when you break things down in that way, actually it becomes easier to make sure that you're getting on to the practicalities of the next steps.

And I really think that's where improvement really comes into its own, because it's very hands on and practical, and equipping people with a big vision, and then these are the problems that need to be solved, now let's get around and find practical ways to address them. 

Matthew Taylor

So that's absolutely, Penny, what I'm hearing from leaders here - you know, because one of the great things about ConfedExpo is you just wander around, bang into people, chat to them - is on the one hand thing we've already emphasised which is vision - this notion that the longest journey starts with a single step. But we do need to have a sense of where that journey is taking us. But the other is we've got to take the pain out of change People are exhausted and if you say to people look this is a change process where things are going to get worse and more difficult they're just going to say no. So having those early wins growing people's confidence is particularly important at a time like this.

Anyway, Penny, that was a bit of my improvement focus workshop here at ConfedExpo, but you chaired a workshop on self-improving system, so what was your session all about?

Penny Pereira 

Well, this workshop was actually all about developing the practical strategies to improve health and care across systems. So it was actually about that work of you've got your big vision, how do you make sure you've co-produced, and you've got really good ownership of that? And then what are the different strands of work that need to come together in order to make that a reality?

The room was full with over 100 people from across health and care joining, which was amazing. We introduced some work that we first developed in Q with our country partners, and which has really come alive as part of our Confed, Q and Health Foundation partnership. Uh, what we've done is we've distilled what's needed for effective improvement across places and systems on a page in a framework.

And that's a framework that allows us to chart a way forward on some of the areas that were raised in the session that we've just been talking about. So we've recognised that different strands of activity need to come together more coherently if we're to reliably deliver the sort of ambitious transformation reimagining work that we're aiming for as a sector.

This means connecting the work to design overall shifts in the model of care that Ben was describing, say, doing that for diabetes or end of life care, and integrating that with the kind of iterative improvement that enables all of the teams who deliver steps along a pathway within the NHS and beyond to understand, adapt and embed the changes that are needed.

And then we need to get much better at pulling in the technological and other innovation work. All the amazing stuff that's in this exhibition wall behind us. We need to make sure that we're really pulling that in and prioritising the things that will support the service shifts that we need. That kind of change delivery programme needs to go hand in hand with creating the shared vision, the leadership, the organisational conditions and capabilities for the work to succeed. 

So the continuous improvement culture that we talked about in your session. These different types of change work, they're happening in every organisation and system, but, you know, split screen thinking and acting is about weaving them together better to make best use of our resources and achieve more reliable, sustainable results.

When it comes to change that spans multiple organisations in a place or a system, there's extra complexities that mean the approach that we take will often be different as, as I think you've said on, on a number of occasions, really helpful. 

So the second thing that our work has been doing is to be specific about this. So we've identified 18 areas that need additional consideration when you're improving across systems. That includes, for example, thinking about co-producing with populations, not just with individual patient groups, or thinking about what it means to meaningfully collaborate with many more partner organisations.

In the workshop, we got into small groups to explore what all this means for people in their individual systems. 

Matthew Taylor

And we were able to grab some quick thoughts from a couple of facilitators who work with you on bringing the session together, Penny. So here they are, Catherine and Mirek, with some of their key takeaways from the session.

Catherine Hall

My name's Catherine Hall, and I work for Gloucestershire ICS where I lead on our system improvement approach. 

If we look at what is happening in health and care, there's so much that can be done individually at the point of care and at various settings across our system. But it's so much more powerful if we look at the whole pathways and how things work together.So having ways where we can collaborate on creating a bigger difference I think is really important. 

I think it takes time. And it takes imagination. As a framework we've been looking at today, it is about how do you get a common vision for what you're aiming to do. And it takes learning about the different cultural experiences and working processes within each of the partners, but finding a way of stepping above that to find new ways of designing, thinking about what the future looks like. So I think it takes a little bit more imagination. 

Mirek Skripak

I'm Mirek Skripak, director of quality improvement at North East London Health Foundation Trust. And I think we're very good at doing our own things in silos. NHS providers are great at that, evidence-based care medicine, but we're being asked to do a lot more as anchor institutions.

But there are other system partners and anchor institutions that, if we collectively think about what the problems are, we can work out some of those solutions together. And a good example today was hearing about post office staff that ask four questions when they deliver mail to assess the vulnerability using NHS AI technology to then send those questions back to primary care and provide some of that intelligence and diagnostic elements, which there's no way we could do that as an NHS provider or a single GP practice. 

Matthew Taylor

So Penny, it's great to hear Catherine and Miric's reflections. Do they ring true for you? 

Penny Pereira

Certainly. I mean, Miric mentions one example of using data in creative ways.

We've talked a number of times in this podcast about the tech and other innovations being showcased at Expo. They hold so much value; so much potential. There's dozens of them here. 

I'm really interested about the way we need to bring that together with improvement methods if we're ever going to realise the potential because I think improvement can complement technological innovation to embed scale, realise the productivity and other benefits.

I think for policy makers, that means that they need to be funding the change, not just the tech. And for health system leaders that means we need to break down some of the silos that can exist between improvement and innovation, for example. Really interested in your thoughts on that. 

Matthew Taylor

Yeah, and I think this is why, Penny, we're doing the work that we're doing with you on system improvement, because it's about recognising what improvement means in the system where collaboration is critical.

But it also links to patients in my speech, I, I talked about a close friend of mine who's had long COVID and I used the example of how she'd had to go to multiple different specialists, different GPs with different perspectives, flare ups in ED. And yet she had the standard symptoms of long COVID.

And I'm interested, this is my own vanity asking you to rate something I said in my speech, but I'm interested Penny in, What you thought of my point about the fact that in the NHS we talk about flow, but when we talk about flow we talk about patients flowing around us, the way we organise things. Don't we need to have the ambition that the services flow around the people?

Penny Pereira

When I heard you say that it really prompted some deep reflection for me because I mean flow is something I've spent a lot of time. 

I hadn't quite reflected on the way in which that language comes across.

I think it's a really important point about how some of the language and terminology we use may lead people to be thinking or understood in a way that certainly from my understanding of flow science is, is quite different from the reality of what we're trying to achieve. 

Rhetorically, it's a very strong and important point thinking about actually who's moving when we're thinking about flow.

In practice, I would say that my experience of doing flow work suggests that creating effective organisations where their processes flow well is the other side of the coin from personalised care where clinicians aren't having to worry about the organisation operating well, and they can then personalise.

I guess I would say one other slightly more technical point, which is when flow ideas first came into the NHS, a lot of the ideas we use were from manufacturing. And there, I think they are taking ideas that have come from factories. There are some parts of healthcare where that is really relevant.

But actually, the most interesting application of flow ideas in healthcare, I think comes from service industries where it's much more about a more flexible, much more kind of person-centred approach to how these ideas can be relevant. 

But the thing that frustrates me is that so often in healthcare, we see ideas that have quite a rich background to them when you really understand them, but these ideas are used quickly, they're thrown around in a way that then ends up not really being deployed or understood in the way that perhaps, you know, you'd hope it might be.

Matthew Taylor

Which brings us back at the very end of our conversation. I need to Weber, the German sociologist, who first analysed bureaucracy. Because one of the things that Weber said about bureaucracies is that they have two sets of goals: substantive goals, which are about what you're ultimately trying to achieve in the world and procedural goals, which are about following the rules and regulations within the organisation.

And what Weber said is that inevitably an organization's procedural rules start to crowd out substantive goals. And that's one of those things you have to guard against. And in our conversation today, which I think has been a lot about the relationship between, you know, improvement and OD. And flow is a good example of this; nobody really goes home at the end of the day to their partner and says, you know what I've done today, darling, I've improved flow.

I think what they might go back and say is, I think I've done something that might make patients’ lives better by improving flow. It's just important always in this, I'm going to end up again with Sarah, always important in this improvement journey to go back to what it's all about, the technique, the mindset, it's all in pursuit of better outcomes. 

Penny Pereira

Indeed. And just as the NHS brings its own acronyms, its own bureaucracy, which starts to distort the, the principles and the value and the purpose that people bring to their work in the NHS. I also cringe when I recognise the improvement world and indeed myself using terminology that also can get in the way of actually what we're talking about here, which is making things better for patients and doing that collaboratively with others.

Sometimes we, we use particular terminology because it helps bring some technical specificity, but it's so easy for that to get in the way of collective understanding and people feeling motivated. And that's so particularly important when you're working across whole systems, because actually you're engaging a much wider set of people who will come from all sorts of professional backgrounds, and it's so easy to lose their engagement and to introduce hierarchy actually by the jargon that you use.

Matthew Taylor

As someone who still feels themselves to be a bit of an outsider in the health world, I can completely relate to that. 

Penny Pereira

I mean, obviously using, referring to Weber is, is one way in which you might make that. 

Matthew Taylor

Oh, but that's just - Weber's not a health person. I mean, okay, I apologise to the world. for my use of it.

It's not an attempt to draw political, to pull up intellectual rank. It's just the great thing about Weber was that he understood the pathologies of organisations. And as leaders, we have to always be aware of those, but I'm being defensive now. 

Penny, finish the conversation before I get myself into deeper trouble.

Penny Pereira

I guess I just wanted to end with one other reflection that came from the workshop we were running this morning is that, yes, you know, system change is really complex. We've touched on a whole range of really complicated issues about how organisations operate, how people lead and work. But when we were getting people together in groups, you're also reminded that actually a lot of the challenges can only be solved when different parts of the sector and places you might not think of initially come together and get in the room.

And that actually there's an awful lot of ideas and energy that are released in that process that help us see a way forward. So we need to lead into what initially might seem quite big, complex, difficult challenges about like the nature of the organisations we're running. And I think we should be confident that if we go about that in the right way, great things will come and that will be the route to kind of reimagining the healthcare service.

Matthew Taylor

Fantastic. Thank you, Penny. 

Well, in the show notes for this podcast, we've shared a link to the Q website, where you can read more about the cross-system improvement framework we've developed. You can see the funky visuals that we hope can support good conversations locally. This thinking is being developed as part of a peer learning programme we're convening as a partnership for 160 leaders of system improvement work in the UK. 

And we're also working with a few systems to test this in practice. So please watch this space for more. 

Thanks to really interesting discussion today, Penny. That's all we've got time for in this episode. It's time for both of us to head back out into the fray here at ConfedExpo.

Penny Pereira

We'll be back next month with more insights from across the improvement world. So please do make sure you subscribe wherever you get your podcasts. And if you like what you heard this week, go ahead and share this episode or get in touch with us to let us know your thoughts. You can find us on X @NHSConfed @HealthFdn and @theQCommunity.

Matthew Taylor

And if you'd like more information about our learning and improvement across systems partnership, please email improvement at NHSConfed.org you can also find transcripts and links to further reading on our website and you'll find the link in the bottom of the podcast description. 

Penny Pereira

Thanks so much and see you next time.

Matthew Taylor

Bye.